Depression—Clinician Algorithm and FAQ

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Screening for Depression in Primary Care: For adults at averagei or increasedii risk for depression we recommend not routinely screening (weak recommendations, very low quality evidence).

This guideline applies to adults (18 years of age or older) who present with no apparent symptoms of depression. It does not apply to individuals with known, past history of, or being treated for depression.

What do these recommendations mean?

Individuals with no apparent symptoms of depression are those who:

do not verbalize their potential depression;

do not present any apparent signs of depression (disposition, facial affect, body language, behaviour); and

do not present clinical clues (Figure 1) of depression.

Screening is not recommended, but may be appropriate in some cases—see scenarios below for examples.

Figure 1: Clinical Clues of Depression (from DSM IV—TR)

Depressed mood

Diminished interest or pleasure

Significant change in weight or appetite

Insomnia or hypersomnia

Psychomotor agitation or retardation

Fatigue or loss of energy

Feeling of worthlessness or excessive/inappropriate guilt

Reduced ability to think or concentrate, or indecisiveness

Recurrent thoughts of death; or suicide plan, attempt, or ideation

How do I implement these recommendations into my practice?

Scenario

Possible actions

Individual has no apparent symptoms; depression is not suspected and the individual does not inquire about depression screening.

or

Individual has no apparent symptoms, but he/she or his/her loved ones inquire about the possibility of depression.

Remain aware of and alert to clinical clues (Figure 1) of depression that the individual may be exhibiting.

Use your knowledge about the individual’s preferences/values and your clinical judgement to determine at what point screening for depression may be appropriate.

Individual has symptoms of depression.

Symptomatic individuals should be appropriately assessed for depression.

Individual has known depression, a past history of depression or is being treated for depression.

This guideline does not apply to this individual.

Frequently asked questions about depression screening

Why is the Canadian Task Force on Preventive Health Care (CTFPHC) recommending not screening adults from average and increased risk groups?

The CTFPHC’s decision to recommend against screening was based on the lack of evidence on the benefits and harms of routinely screening adults with no apparent symptoms of depression. Despite the lack of evidence, the CTFPHC had concerns about the potential harms of screening, (e.g. false positives and unnecessary treatment).

In the absence of a demonstrated benefit of screening, and considering the potential harms, the CTFPHC recommends not routinely screening adults from average and increased risk groups with no apparent symptoms of depression.iii

How is “screening” defined?

Screening refers to posing targeted questions or administering a survey/questionnaire to all adults with no apparent symptoms of depression to identify those who may have depression. Screening can range from systematically asking one or two questions about depression to using a comprehensive screening tool.

How can I remain alert to potential depression without asking an individual questions about his/her psychological well-being?

Individuals may present with signs and/or clinical clues of depression, some of which are apparent without asking the individual. Additionally, some individuals presenting with other medical issues may have undiagnosed depression. Clinicians should be aware of depression symptoms, both verbal and non-verbal, for example:

Remain open and sensitive to changes in disposition, facial affect, body language or behaviour during a clinical encounter; these signs can help identify potential depression.

Remain alert to clues disclosed by an individual that he/she may not relate to depression but may indicate that depression is present (Figure 1, previous page).

Pay attention to the clinical clues of depression and assess symptomatic adults when appropriate.

My clinic asks standard questions about mood and signs of depression on our individual intake forms, during primary care visits, and in other forms/services. Is this considered screening for depression?

If a validated screening instrument is being applied, then yes, this is considered a form of screening. As stated previously, it is important to remember that screening instruments can range from one or two questions to a series of questions.

The CTFPHC does not recommend screening individuals with no apparent symptoms of depression, but individual practitioners or clinics may consider their practice settings to decide when screening is appropriate. For example, integrated staff-assisted systems (i.e. primary care settings engaging nonmedical specialists in providing depression management and follow-up) may be more effective in increasing response to treatment. Clinicians practicing in a setting where there are integrated, staff-assisted systems may be more inclined to offer screening through standard forms or in primary care visits given that treatment is more likely to be effective when these systems are available.

Guidelines from other organizations for specific conditions or populations (e.g. postpartum women) indicate that I should screen for depression. Which guideline should I follow?

The CTFPHC offers a weak recommendation for depression screening; this means that although this course of action is appropriate for most people, it may not be appropriate for others. Clinicians should consider the CTFPHC guideline and use their knowledge of an individual’s history, physical health condition, preferences and values to determine a suitable course of action.

Notes

The average risk group includes all individuals 18 years of age or older with no apparent symptoms of depression.

Subgroups of the population who may be at increased risk of depression include: family history of depression, traumatic childhood/recent life events, chronic health problems, substance misuse, perinatal and post-partum status, Aboriginal origin.

Detailed descriptions of methods used by the CTFPHC, which include the application of the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to determine the strength of the recommendations, are available on the CTFPHC website.

Before each meeting, every member of the Canadian Task Force on Preventive Health Care (CTFPHC) and of the Evidence Review and Synthesis Centre (ERSC) completes a Declaration of Affiliations and Interests Form to report any potential conflicts of interest (e.g., financial, business or professional, intellectual). Disclosure is required for each new topic, and disclosures must be updated to reflect any changes that have occurred since an initial disclosure. Completed forms are kept on file, and outside experts who are asked to comment on the recommendations and documents prepared by the CTFPHC are also required to complete disclosure forms, which are kept on file. For more information, please refer to the CTFPHC’s Procedure Manual.